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Methods of Documentation V: CBE

Methods of Documentation V: CBE

Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...

Methods of Documentation I: Source-Oriented Records

Methods of Documentation I: Source-Oriented Records

Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:

Methods of Documentation IV: Focus Charting

Methods of Documentation IV: Focus Charting

Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
It typically involves three columns for recording information:

Independent and Dependent Sources

Independent and Dependent Sources

In electrical circuits, sources play a crucial role in providing power for the operation of the circuit. These sources can be broadly categorized into two types: independent and dependent.
Independent voltage or current sources supply a fixed amount of voltage or current, respectively, which is unaffected by other elements within the circuit. These are represented using specific symbols. Independent voltage sources are symbolized with polarities (+ and -), indicating the direction of the...

Legal Guidelines for Documentation

Legal Guidelines for Documentation

The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:

Attribution Theory

Attribution Theory

Behavior is a product of both the situation (e.g., cultural influences, social roles, and the presence of bystanders) and of the person (e.g., personality characteristics). Subfields of psychology tend to focus on one influence or behavior over others. Situationism is the view that our behavior and actions are determined by our immediate environment and surroundings. In contrast, dispositionism holds that our behavior is determined by internal factors (Heider, 1958). An internal factor is an...

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Citation, citation, citation

Kumara Mendis¹, Chris van Weel, Christopher Del Mar

¹School of Rural Health, University of Sydney, Australia. kumara.mendis@sydney.edu.au

The British Journal of General Practice : the Journal of the Royal College of General Practitioners

|September 9, 2010

Summary

No abstract available in PubMed .

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